DYRK 1 A haploinsufficiency a frequent cause of

DYRK 1 A haploinsufficiency, a frequent cause of microcephaly and developmental delay? M. Holder-Espinasse muriel. holder@gstt. nhs. uk DYRK 1 A family group 21 st July 2018

Clinical Genetics • • • Prenatal diagnosis Postnatal diagnosis Children and adults Isolated, associated or syndromic Genetic counselling/recurrence risks/future pregnancies

Clinical Genetics • • 45 min appointment Family history/pedigree Medical history Clinical examination Growth parameters Photographs X-rays Blood (EDTA and lith hep)/saliva/skin samples for genetic testing and consent

Genetic testing • • Free fetal DNA Karyotype Array CGH MLPA q. PCR Single gene sequencing WES WGS

Karyotype Chromosome rearrangement

Imbalance

MLPA deletion, duplication q. PCR

Sequencing WGS WES mutation

Ø Whole exome sequencing • Different types of genes panel • ID, microcephaly, epilepsy, cortical malformations… Ø Whole genome sequencing • 100 K • Diagnostic test in very near future

Introduction • DYRK 1 A : 21 q 22. 13 (17 exons, 754 AA) • Dual-specificity tyrosine phosphorylation-regulated kinase family • Human orthologue of Drosophila (mnb)/postembryonic neurogenesis minibrain • Correlation of functions in the brain/Down syndrome gene

Introduction • Important role in controlling brain size and structure • Brain growth/neuronal proliferation and neurogenesis in a gene dosage dependent manner • DYRK 1 A haploinsufficiency: reduced brain size • DYRK 1 A gain-of-function: increased brain size • Tau phosphorylation/mouse model of Down syndrome

Mouse models • Gene-targeting disruption of Dyrk 1 a in mice: decreased body and brain size, with no severe disturbance of behaviour • Dyrk 1 a (+/-) mice: impairment of neuromotor development with decreased activity. In adult, marked hypoactivity and alteration of specific motor parameters Fotaki et al. 2002. Mol Cell Biol 22: 6636 -6647

Mouse models Fotaki et al. 2002. Mol Cell Biol 22: 6636 -6647

DYRK 1 A… 10 years ago Am J Hum Genet, 2008; 82: 1165– 1170 J Med Genet, 2012; 49: 731– 736

Our experience • Collaboration between Guy’s, Northampton, Manchester, Oxford, Birmingham, Edinburgh, Sidney and Leuven • 2 de novo (2 and 3 Mb) deletion at 21 q 22. 12 including DYRK 1 A • 1 de novo 20 kb deletion at 21 q 22. 12 which disrupts and partially deletes DYRK 1 A • 7 DYRK 1 A de novo mutations through • 1 DYRK 1 A de novo mutation through WES

Patient 1 2 3 4 5 6 7 8 9 10 11 Guy’s Northampton Manchester Oxford Birmingham Edinburgh / Sydney Leuven Birmingha m F M F F M M M F F M F Age at diagnosis 12 y 11 y 1 w 19 y 6 y 6 y 12 y 6 y 8 y 6 y 4 y Height 2 nd 2 nd 2 nd 9 th 0. 4 th 2 nd Weight 2 nd-9 th 2 nd 2 nd-9 th 9 th 2 nd Microcephaly + + + Deep set eyes Micrognathia Thin upper lip + + + + + + + Epilepsy + + - ID + + + Behaviour + + - + + + - - - Brain MRI CA Thin CC WML Not done Normal CCA Dysplastic CC CA VM WML Thin CC Delayed myelinatio n Optic nerve hypoplasi a VM Thin CC Cerebellar hypoplasia Not done Hallux valgus Neurological deterioration Coloboma Pulmonar y stenosis c. 1036 T>C c. 691 C>T Sex Additional findings DYRK 1 A Deletion 2 Mb c. 263 del. C c 393_394 GGdup Feeding difficulties Cataract Optic nerve hypoplasia Hypermetropia Joint laxity Cleft palate Contractures Scoliosis Neurological deterioration Hallux valgus Bicuspid aortic valve Coarctation of the aorta Pectus excavatum 5 th finger clinodactyl y c. 860 A>T c. 620 T>C Deletion 20 kb c. 1036 del T c. 1309 C>T Deletion 3 Mb

Patient 1 2 3 4 5 6 7 8 9 10 11 Guy’s Northampton Manchester Oxford Birmingham Edinburgh / Sydney Leuven Birmingha m F M F F M M M F F M F Age at diagnosis 12 y 11 y 1 w 19 y 6 y 6 y 12 y 6 y 8 y 6 y 4 y Height 2 nd 2 nd 2 nd 9 th 0. 4 th 2 nd Weight 2 nd-9 th 2 nd 2 nd-9 th 9 th 2 nd Microcephaly + + + Deep set eyes Micrognathia Thin upper lip + + + + + + + Epilepsy + + - ID + + + Behaviour + + - + + + - - - Brain MRI CA Thin CC WML Not done Normal CCA Dysplastic CC CA VM WML Thin CC Delayed myelinatio n Optic nerve hypoplasi a VM Thin CC Cerebellar hypoplasia Not done Hallux valgus Neurological deterioration Coloboma Pulmonar y stenosis c. 1036 T>C c. 691 C>T Sex Additional findings DYRK 1 A Deletion 2 Mb c. 263 del. C c 393_394 GGdup Feeding difficulties Cataract Optic nerve hypoplasia Hypermetropia Joint laxity Cleft palate Contractures Scoliosis Neurological deterioration Hallux valgus Bicuspid aortic valve Coarctation of the aorta Pectus excavatum 5 th finger clinodactyl y c. 860 A>T c. 620 T>C Deletion 20 kb c. 1036 del T c. 1309 C>T Deletion 3 Mb

Patient 1 2 3 4 5 6 7 8 9 10 11 Guy’s Northampton Manchester Oxford Birmingham Edinburgh / Sydney Leuven Birmingha m F M F F M M M F F M F Age at diagnosis 12 y 11 y 1 w 19 y 6 y 6 y 12 y 6 y 8 y 6 y 4 y Height 2 nd 2 nd 2 nd 9 th 0. 4 th 2 nd Weight 2 nd-9 th 2 nd 2 nd-9 th 9 th 2 nd Microcephaly + + + Deep set eyes Micrognathia Thin upper lip + + + + + + + Epilepsy + + - ID + + + Behaviour + + - + + + - - - Brain MRI CA Thin CC WML Not done Normal CCA Dysplastic CC CA VM WML Thin CC Delayed myelinatio n Optic nerve hypoplasi a VM Thin CC Cerebellar hypoplasia Not done Hallux valgus Neurological deterioration Coloboma Pulmonar y stenosis c. 1036 T>C c. 691 C>T Sex Additional findings DYRK 1 A Deletion 2 Mb c. 263 del. C c 393_394 GGdup Feeding difficulties Cataract Optic nerve hypoplasia Hypermetropia Joint laxity Cleft palate Contractures Scoliosis Neurological deterioration Hallux valgus Bicuspid aortic valve Coarctation of the aorta Pectus excavatum 5 th finger clinodactyl y c. 860 A>T c. 620 T>C Deletion 20 kb c. 1036 del T c. 1309 C>T Deletion 3 Mb

Patient 1 2 3 4 5 6 7 8 9 10 11 Guy’s Northampton Manchester Oxford Birmingham Edinburgh / Sydney Leuven Birmingha m F M F F M M M F F M F Age at diagnosis 12 y 11 y 1 w 19 y 6 y 6 y 12 y 6 y 8 y 6 y 4 y Height 2 nd 2 nd 2 nd 9 th 0. 4 th 2 nd Weight 2 nd-9 th 2 nd 2 nd-9 th 9 th 2 nd Microcephaly + + + Deep set eyes Micrognathia Thin upper lip + + + + + + + Epilepsy + + - ID + + + Behaviour + + - + + + - - - Brain MRI CA Thin CC WML Not done Normal CCA Dysplastic CC CA VM WML Thin CC Delayed myelinatio n Optic nerve hypoplasi a VM Thin CC Cerebellar hypoplasia Not done Hallux valgus Neurological deterioration Coloboma Pulmonar y stenosis c. 1036 T>C c. 691 C>T Sex Additional findings DYRK 1 A Deletion 2 Mb c. 263 del. C c 393_394 GGdup Feeding difficulties Cataract Optic nerve hypoplasia Hypermetropia Joint laxity Cleft palate Contractures Scoliosis Neurological deterioration Hallux valgus Bicuspid aortic valve Coarctation of the aorta Pectus excavatum 5 th finger clinodactyl y c. 860 A>T c. 620 T>C Deletion 20 kb c. 1036 del T c. 1309 C>T Deletion 3 Mb

Patient 1 2 3 4 5 6 7 8 9 10 11 Guy’s Northampton Manchester Oxford Birmingham Edinburgh / Sydney Leuven Birmingha m F M F F M M M F F M F Age at diagnosis 12 y 11 y 1 w 19 y 6 y 6 y 12 y 6 y 8 y 6 y 4 y Height 2 nd 2 nd 2 nd 9 th 0. 4 th 2 nd Weight 2 nd-9 th 2 nd 2 nd-9 th 9 th 2 nd Microcephaly + + + Deep set eyes Micrognathia Thin upper lip + + + + + + + Epilepsy + + - ID + + + Behaviour + + - + + + - - - Brain MRI CA Thin CC WML Not done Normal CCA Dysplastic CC CA VM WML Thin CC Delayed myelinatio n Optic nerve hypoplasi a VM Thin CC Cerebellar hypoplasia Not done Hallux valgus Neurological deterioration Coloboma Pulmonar y stenosis c. 1036 T>C c. 691 C>T Sex Additional findings DYRK 1 A Deletion 2 Mb c. 263 del. C c 393_394 GGdup Feeding difficulties Cataract Optic nerve hypoplasia Hypermetropia Joint laxity Cleft palate Contractures Scoliosis Neurological deterioration Hallux valgus Bicuspid aortic valve Coarctation of the aorta Pectus excavatum 5 th finger clinodactyl y c. 860 A>T c. 620 T>C Deletion 20 kb c. 1036 del T c. 1309 C>T Deletion 3 Mb

Patient 1 2 3 4 5 6 7 8 9 10 11 Guy’s Northampton Manchester Oxford Birmingham Edinburgh / Sydney Leuven Birmingha m F M F F M M M F F M F Age at diagnosis 12 y 11 y 1 w 19 y 6 y 6 y 12 y 6 y 8 y 6 y 4 y Height 2 nd 2 nd 2 nd 9 th 0. 4 th 2 nd Weight 2 nd-9 th 2 nd 2 nd-9 th 9 th 2 nd Microcephaly + + + Deep set eyes Micrognathia Thin upper lip + + + + + + + Epilepsy + + - ID + + + Behaviour + + - + + + - - - Brain MRI CA Thin CC WML Not done Normal CCA Dysplastic CC CA VM WML Thin CC Delayed myelinatio n Optic nerve hypoplasi a VM Thin CC Cerebellar hypoplasia Not done Hallux valgus Neurological deterioration Coloboma Pulmonar y stenosis c. 1036 T>C c. 691 C>T Sex Additional findings DYRK 1 A Deletion 2 Mb c. 263 del. C c 393_394 GGdup Feeding difficulties Cataract Optic nerve hypoplasia Hypermetropia Joint laxity Cleft palate Contractures Scoliosis Neurological deterioration Hallux valgus Bicuspid aortic valve Coarctation of the aorta Pectus excavatum 5 th finger clinodactyl y c. 860 A>T c. 620 T>C Deletion 20 kb c. 1036 del T c. 1309 C>T Deletion 3 Mb

Patient 1 2 3 4 5 6 7 8 9 10 11 Guy’s Northampton Manchester Oxford Birmingham Edinburgh / Sydney Leuven Birmingha m F M F F M M M F F M F Age at diagnosis 12 y 11 y 1 w 19 y 6 y 6 y 12 y 6 y 8 y 6 y 4 y Height 2 nd 2 nd 2 nd 9 th 0. 4 th 2 nd Weight 2 nd-9 th 2 nd 2 nd-9 th 9 th 2 nd Microcephaly + + + Deep set eyes Micrognathia Thin upper lip + + + + + + + Epilepsy + + - ID + + + Behaviour + + - + + + - - - Brain MRI CA Thin CC WML Not done Normal CCA Dysplastic CC CA VM WML Thin CC Delayed myelinatio n Optic nerve hypoplasi a VM Thin CC Cerebellar hypoplasia Not done Hallux valgus Neurological deterioration Coloboma Pulmonar y stenosis c. 1036 T>C c. 691 C>T Sex Additional findings DYRK 1 A Deletion 2 Mb c. 263 del. C c 393_394 GGdup Feeding difficulties Cataract Optic nerve hypoplasia Hypermetropia Joint laxity Cleft palate Contractures Scoliosis Neurological deterioration Hallux valgus Bicuspid aortic valve Coarctation of the aorta Pectus excavatum 5 th finger clinodactyl y c. 860 A>T c. 620 T>C Deletion 20 kb c. 1036 del T c. 1309 C>T Deletion 3 Mb

Patients • Microcephaly (congenital/progressive) 11/11 • ID (moderate to severe)/Behaviour 11/11 • Epilepsy (8/11)/Brain anomalies (5/11) • Common facial features (deep-set eyes, micrognathia, thin upper lip) • Growth retardation (11/11) • Cleft palate, feeding difficulties, GOR, coloboma, cataract and pulmonary stenosis

Your experience ? • Microcephaly • ID/Behaviour • Epilepsy • Brain anomalies • Facial features • Growth retardation • Additional findings

DYRK 1 A deletions Patient 3 Patient 8

DDD/Decipher/GEL update • 77 patients in Decipher/15000 (deletion, duplication, mutation) • 1 in GEL (11000)

DYRK 1 A variants c. 620 T>C p. (Leu 207 Pro) c. 860 A>T p. (Asp 287 Val) c. 393_394 GGdup p. (Glu 132 Glyfs) c. 263 del. C p. (Pro 88 fs) c. 691 C>T c. 1036 T>C p. (Arg 231 Ter) p. (Ser 346 Pro) Patient 2 Patient 4 Patient 5 Patient 7 Patient 1 Patient 6

Therapeutics • DYRK 1 A most extensively studied gene/chromosome 21 • Remarkable correlation/brain function/Down Syndrome neuropathologies (neuronal deficit, Alzheimer’s like, cognitive impairment…) • Overexpression may induce DS-like phenotype • Attractive target • Inhibitors of protein kinase activity are available

Recent literature

Conclusion • DYRK 1 A is one of the most frequent gene involved in ID with microcephaly • Recognisable facial features • Potential therapeutic implications

Acknowledgements • Clinicians Charu Deshpande Frances Flinter Leema Robert Mina Ryten Caroline Olgivie Derek Lim Jill Clayton-Smith Sue Price Usha Kini • Decipher consortium • Patients and their families • Scientists Louise Bicknell Paula Carroll Meredith Wilson Nicola Ragge Alisdair Mc. Neill Koenradt Devrient Jacoba Louw Marc Gewillig Caroline Olgivie

Thank you